Noninvasive revascularization by enhanced external counterpulsation: a case study and literature review

Nearly 8 million people in the United States suffer from symptoms of coronary artery disease (CAD). Unfortunately, the population of patients with ischemic coronary disease that is not readily amenable to surgical or percutaneous revascularization continues to grow. For patients who are not candidates for standard revascularization procedures and in whom aggressive medical therapy fails to control symptoms, enhanced external counterpulsation (EECP) is a new, noninvasive outpatient method to improve quality of life by decreasing ischemic symptoms and permit increased activity. We report the case of a 56-year-old woman with severe, symptomatic CAD receiving maximal medical therapy who underwent a course of EECP therapy because she was not a good candidate for other forms of revascularization. She demonstrated dramatic improvement in her anginal symptoms and complete resolution of myocardial ischemia on repeat nuclear stress imaging. This case suggests that EECP is a safe and effective method for reducing symptoms of myocardial ischemia in patients for whom standard percutaneous or surgical revascularization is not suitable treatment.     

Evaluation of sperm telomere length in infertile men with failed/low fertilization after intracytoplasmic sperm injection

Research question

Telomeres are non-coding, repetitive DNA sequences (TTAGGG repeats) that play an important role in maintaining genome integrity. Unlike in somatic cells, telomere length in spermatozoa increases with male age and is considered as a molecular marker of sperm quality. The aetiology of failed fertilization following intracytoplasmic sperm injection (ICSI) is multifactorial; perhaps one of the reasons for this failure in these individuals is shortened sperm telomere length. This study therefore aimed to assess sperm telomere length in addition to DNA damage, lipid peroxidation and protamine deficiency in infertile men with previously failed/low fertilization post-ICSI.

Medical and surgical outcome of tricuspid regurgitation caused by flail leaflets

OBJECTIVE: We sought to evaluate the medical and surgical outcome of tricuspid regurgitation caused by flail leaflets. METHODS: We analyzed the cause, clinical presentation, outcome, and natural history of 60 patients with tricuspid regurgitation caused by flail leaflets, a cause of mostly severe and organic tricuspid regurgitation, diagnosed by means of echocardiography between 1980 and 2000. RESULTS: The main cause was traumatic (62%). Clinical presentation was often severe: 57% were symptomatic, 33% had a history of congestive heart failure, and 40% had a history of atrial fibrillation. Compared with expected survival of the US matched population, excess mortality (39% +/- 10% at 10 years or 4.5% yearly, P <.01) was observed. Even patients asymptomatic at presentation experienced high tricuspid-related event rates (at 10 years, 75% +/- 15% had symptoms or heart failure, atrial fibrillation, surgical intervention, or death). In those patients severe enlargement of right-sided chambers was predictive of poor outcome (at 5 years: 86% +/- 9% vs 39% +/- 11%, P <.01) independent of cause (P =.31). The poor medical outcome was further confirmed by high event rates (69% +/- 9% at 15 years) in the natural history beginning from the flail's occurrence. Tricuspid operations were performed in 33 patients (55% +/- 7% at 5 years), with valve repair in 82%, low mortality (3%), and, despite frequently refractory atrial fibrillation, symptomatic improvement in 88%. CONCLUSION: Tricuspid regurgitation caused by flail leaflets is a serious disease associated with excess mortality and high morbidity. Tricuspid valve repair can often be performed with low risk, allowing symptomatic improvement. These results suggest that surgical intervention should be considered early in the course of the disease before the occurrence of irreversible consequences.     

C-reactive protein and atherosclerosis of the thoracic aorta: a population-based transesophageal echocardiographic study

BACKGROUND: An association between systemic inflammatory markers and the presence and severity of atherosclerotic plaques has not been demonstrated in a nonselected population. The purpose of this study was to examine the association of inflammatory markers with aortic atherosclerotic plaques in a sample of the general population and in a subgroup free of clinical vascular disease. METHODS: Transesophageal echocardiography was performed in 386 subjects (median age, 66 years; 53% men). We examined the association between systemic inflammatory markers and aortic atherosclerotic plaques. RESULTS: Aortic plaques were present in 267 subjects (69%). Plaques at least 4 and 6 mm thick and mobile debris were present in 114, 41, and 20 subjects, respectively. High-sensitivity C-reactive protein (hs-CRP) level was associated with the presence of aortic plaques, adjusting for age, sex, smoking status, and additional atherosclerosis risk factors. Among subjects with plaques, hs-CRP level was independently associated with plaques at least 6 mm thick; similar trends were observed for the associations of hs-CRP level with plaques at least 4 mm thick and mobile debris. In subjects with aortic plaques who were free of clinically apparent coronary artery or cerebrovascular disease, hs-CRP level was independently associated with plaques at least 6 mm thick. CONCLUSIONS: Level of hs-CRP is independently associated with the presence and severity of aortic atherosclerotic plaques. These observations establish the association of systemic inflammation with anatomically defined atherosclerosis in the general population.